The efficacy of pentoxifylline/tocopherol combination in the treatment of osteoradionecrosis

Is the use of Pentoxifylline and Tocopherol effective in the treatment of Osteoradionecrosis of the jaws or for the treatment of medicationosteonecrosis of the jaw? An overview

PURPOSE

The aim of the present study was to determine the methodological quality of systematic reviews that evaluated the effectiveness of pentoxifylline and tocopherol (PENTO) in the treatment of osteoradionecrosis of the jaw (ORNJ) and medication-related osteonecrosis of the jaw (MRONJ).

METHODS

Searches were performed in Databases including PubMed, Scopus, LILACS, DARE, Cochrane Library, and SIGLE through OpenGrey until March 2024, were evaluated by two independent reviewers to answer the following question: Is the use of PENTO protocol effective in the treatment of ORNJ or for the treatment of MRONJ?

RESULTS

A total of 256 articles were initially identified; however, following the use of appropriate inclusion and exclusion criteria, five systematic reviews were identified for detailed analysis. The final study sample comprised 588 patients: 397 patients with ORN and 197 patients with MRONJ who were treated with PENTO. The total recovery of individuals who used the PENTO protocol was 62,2 % for ORN and 100 % for MRONJ, with a follow-up period of 1 month to 10 years. The methodological quality of the studies was assessed using the AMSTAR 2 tool, in which four were of low quality and 1 moderate quality.

CONCLUSION

The treatment of ORN and MRONJ with pentoxifylline and tocopherol has shown good results in the studies presented, with a partial or total reduction in bone exposure. However, the low quality of the relevant reports highlights the need for primary and secondary studies with better methodological rigor to reduce bias and provide reassurance for this treatment option.

Prevention and Management of Osteoradionecrosis in Patients With Head and Neck Cancer Treated With Radiation Therapy: ISOO-MASCC-ASCO Guideline

PURPOSE

To provide evidence-based recommendations for prevention and management of osteoradionecrosis (ORN) of the jaw secondary to head and neck radiation therapy in patients with cancer.

METHODS

The International Society of Oral Oncology-Multinational Association for Supportive Care in Cancer (ISOO-MASCC) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials and observational studies, published between January 1, 2009, and December 1, 2023. The guideline also incorporated systematic reviews conducted by ISOO-MASCC, which included studies published from January 1, 1990, through December 31, 2008.

RESULTS

A total of 1,539 publications were initially identified. There were 487 duplicate publications, resulting in 1,052 studies screened by abstract, 104 screened by full text, and 80 included for systematic review evaluation.

RECOMMENDATIONS

Due to limitations of available evidence, the guideline relied on informal consensus for some recommendations. Recommendations that were deemed evidence-based with strong evidence by the Expert Panel were those pertaining to best practices in prevention of ORN and surgical management. No recommendation was possible for the utilization of leukocyte- and platelet-rich fibrin or photobiomodulation for prevention of ORN. The use of hyperbaric oxygen in prevention and management of ORN remains largely unjustified, with limited evidence to support its practice.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Prophylactic Use of Pentoxifylline and Tocopherol for Prevention of Osteoradionecrosis of the Jaw after Dental Extraction in Post-Radiated Oral and Oropharyngeal Cancer Patients: An Initial Case Series

Osteoradionecrosis of the jaw is a morbid complication of radiotherapy in patients with oral and oropharyngeal cancers that may be precipitated by dental extractions. Pentoxifylline and tocopherol (PENTO) has been utilized in the management of osteoradionecrosis and as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. This observational study aims to report the outcome of the prophylactic use of PENTO in the prevention of osteoradionecrosis of the jaw after dental extractions in post-radiated oral and oropharyngeal cancer patients and to review the current literature on this topic. Four post-radiated oral and oropharyngeal oncology patients were referred to the dental oncology clinic of the University Dental Practice, University of Tennessee Health Sciences Center for dental extractions. All four patients were prescribed pentoxifylline 400 mg BID (twice a day) and tocopherol 400 IU BID (oral tablets) for 2 weeks before extraction(s) and for 6 weeks after extraction(s). All patients were followed up every week after the second week post-extraction if feasible until the extraction site(s) healed (covered by mucosa). The assessment endpoint was defined as 6 weeks post-extraction with the outcomes assessed as using four categories determined by the area of exposed bone: complete healing (complete mucosal coverage of extraction site); partial healing (reduction in size of extraction site); no change; and progression (increase in size of the extraction site). At the assessment endpoint, all patients had complete healing of all extraction sites. The ORN rate at the patient level (0/4) and individual tooth level (0/8) was 0%. All patients tolerated the PENTO medications and no adverse effects from the use of these medications were reported. This limited study in addition to the other reviewed studies estimates the rate of ORN at the patient level as 3.2% (14/436) for post-radiated head and neck oncology patients after dental extractions/invasive oral procedures. In conclusion, this PENTO regimen can reduce/prevent the incidence of ORN in post-radiated head and neck oncology patients. This safe and cost-effective protocol (PENTO regimen) should be further evaluated as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. We recommend large prospective studies to be carried out to further validate these findings.

Noninvasive Systemic Modalities for Prevention of Head and Neck Radiation-Associated Soft Tissue Injury: A Narrative Review

BACKGROUND

 Radiation-associated soft tissue injury is a potentially devastating complication for head and neck cancer patients. The damage can range from minor sequelae such as xerostomia, which requires frequent daily maintenance, to destructive degenerative processes such as osteoradionecrosis, which can contribute to flap failure and delay or reverse oral rehabilitation. Despite the need for effective radioprotectants, the literature remains sparse, primarily focused on interventions beyond the surgeon's control, such as maintenance of good oral hygiene or modulation of radiation dose.

METHODS

 This narrative review aggregates and explores noninvasive, systemic treatment modalities for prevention or amelioration of radiation-associated soft tissue injury.

RESULTS

 We highlighted nine modalities with the most clinical potential, which include amifostine, melatonin, palifermin, hyperbaric oxygen therapy, photobiomodulation, pentoxifylline-tocopherol-clodronate, pravastatin, transforming growth factor-β modulators, and deferoxamine, and reviewed the benefits and limitations of each modality. Unfortunately, none of these modalities are supported by strong evidence for prophylaxis against radiation-associated soft tissue injury.

CONCLUSION

 While we cannot endorse any of these nine modalities for immediate clinical use, they may prove fruitful areas for further investigation.

The Potential Therapeutic Role of Mesenchymal Stem Cells-Derived Exosomes in Osteoradionecrosis

As one of the most serious complications of radiotherapy, osteoradionecrosis (ORN) seriously affects the quality of life of patients and even leads to death. Vascular injury and immune disorders are the main causes of bone lesions. The traditional conservative treatment of ORN has a low cure rate and high recurrent. Exosomes are a type of extracellular bilayer lipid vesicles secreted by almost all cell types. It contains cytokines, proteins, mRNA, miRNA, and other bioactive cargos, which contribute to several distinct processes. The favorable biological functions of mesenchymal stem cells-derived exosomes (MSC exosomes) include angiogenesis, immunomodulation, bone regeneration, and ferroptosis regulation. Exploring the characteristic of ORN and MSC exosomes can promote bone regeneration therapies. In this review, we summarized the current knowledge of ORN and MSC exosomes and highlighted the potential application of MSC exosomes in ORN treatment.

Pentoxifylline and tocopherol (vitamin E) with/without clodronate for the management of osteoradionecrosis: A scoping review

BACKGROUND

Treatment of osteoradionecrosis (ORN) is not a straightforward task, and it is unpredictable. However, a combination of pentoxifylline; an antioxidant drug, and tocopherol (vitamin E) works as a potent antifibrotic agent and have shown recently both significant and impressive results.

AIMS

This scoping review aims to investigate the most prescribed regimen of pentoxifylline and tocopherol with/without clodronate for the management of ORN.

METHODS

Ovid MEDLINE and EMBASE databases were used to retrieve eligible studies using planned search keywords. PROSPERO and Cohcarne library were also searched for ongoing or published systematic reviews, respectively. Included articles were grouped thematically according to the type of studies and accordingly they were summarized.

RESULTS

A total of 27 articles met the inclusion criteria and included in the data analyses. All the included articles were published between 1997 and 2020. Of these 27 included studies, two were randomized control trials, two were systematic reviews, six were retrospective studies, five were observational studies, seven were narrative reviews, four were case reports, and lastly one was an in-vitro study.

CONCLUSIONS

Treatment by PENTO (800 mg of pentoxifylline + 1000 IU of tocopherol) once daily for an early established ORN or PENTOCLO (PENTO regimen + 1600 mg of clodronate) once daily for the refractory/severe cases of ORN appears to be the most prescribed regimen used for the treatment of ORN using these drugs. These drugs appear safe, effective and inexpensive for the treatment of ORN.

Gastrointestinal Toxicity of Pelvic Radiotherapy: Are We Letting Women Down?

For all cancers there are four areas of importance: prevention, early diagnosis, optimising therapy and living with and beyond. For women diagnosed with gynaecological cancers, progress in these first three areas has been immense. However, living with and beyond has largely been ignored as a significant issue. As a group, patients treated for gynaecological cancer are more often young and more often suffer the most difficult long-term issues. Despite the growing number of long-term survivors, little has been done to ensure appropriate assessment and treatment of side-effects of cancer therapies, especially when radiotherapy has been used. For many affected patients their symptoms become part of everyday life, 'normality' is adjusted and these changes are tolerated even when severely limiting activities. Data show that even expert clinicians frequently do not appreciate the true impact of these problems and the focus of treatment and of follow-up remains fixed on 5-year survival and cancer recurrence, respectively. Many clinicians are unaware of what experts can do for toxicity and do not know where to refer their patients. However, rapid identification of patients with significant symptoms can lead to earlier diagnosis of treatable pathologies and improvement in patients' quality of life. In addition, the underlying pathophysiology of radiation-induced damage is potentially amenable to disease-modifying therapies. This review focuses on the factors that contribute to patients developing pelvic radiation disease, what can be done to mitigate the toxicity of treatment and highlights the challenges that must be addressed to reduce the gastrointestinal toxicity of pelvic radiotherapy.

The use of pentoxifylline, tocopherol and clodronate in the management of osteoradionecrosis of the jaws

AIMS

Medical management of osteoradionecrosis (ORN) via pentoxifylline, tocopherol (PENTO) and clodronate (PENTOCLO) has shown both promise and early positive outcomes. We aimed to determine clinical outcomes for patients with established ORN managed solely via PENTO or PENTOCLO.

METHODS

The study retrospectively reviewed and collected data from the medical records of 169 patients diagnosed with ORN and treated via medical management. Patients that received any additional interventions such as surgery or hyperbaric oxygen were not included.

RESULTS

Medical management led to healed ORN in 54.4% (n = 92/169) of patients after an average of 12.9 months. Outcome comparison between PENTO and PENTOCLO identified the former regime to be significantly superior (p = 0.0001). There is an inverse relationship with increasing ORN severity and healing with medical management (p < 0.0001) with oropharyngeal cancer (p = 0.0347) patients responding favourably via this approach. Infection had a critical role in the final outcome with those healing requiring 1.3 antibiotic prescriptions, while those that had disease progression requiring 4.3 prescriptions.

CONCLUSION

Medical management is a viable treatment option for ORN. It appears to be most effective in Notani I and non-infected ORN. When healing was not achieved the regime was able to stabilise the condition.

Fasciocutaneous Flaps for Refractory Intermediate Stage Osteoradionecrosis of the Mandible-Is It Time for a Shift in Management?

PURPOSE

Historically, free tissue transfer has been reserved for advanced stage osteoradionecrosis (ORN) of the jaw with pathologic fracture or cutaneous fistula. The purpose of this study was to evaluate if in patients with recalcitrant intermediate stage ORN, would mandibular debridement in combination with vascularized soft tissue coverage result in durable symptom and disease resolution.

PATIENTS AND METHODS

A retrospective cohort study of patients with mandibular ORN was performed comparing a mandibular preserving approach with a fasciocutaneous forearm flap for progressive treatment-resistant intermediate stage ORN to mandibulectomy and vascularized bone flap (VBF) reconstruction for advanced stage ORN. The primary outcome was ORN resolution.

RESULTS

The sample was composed of 35 patients. One-hundred percent of patients undergoing a mandibular preserving approach experienced ORN resolution compared with 83.3% in the segmental mandibulectomy and VBF reconstruction group (P = .28). Patients in the mandibular preservation group experienced a shorter hospitalization (6 vs 9 days; P = .07), decreased length of surgery (384.9 vs 406.3 minutes; P = .01), and less delayed healing requiring local wound care (9.1 vs 45.8% of patients; P = .06).

CONCLUSIONS

A mandibular preserving approach is successful at arresting intermediate stage ORN and is associated with a decreased operative time, a shorter hospitalization, and less need for prolonged wound care when compared with VBF reconstruction for advanced stage ORN.

Chinese expert group consensus on diagnosis and clinical management of osteoradionecrosis of the mandible

Osteoradionecrosis of the mandible (MORN) is one of the most devastating complications caused by radiation therapy in the head and neck region. It is characterized by infection and chronic necrosis of the mandible as the main manifestation. Clinically, MORN-related symptoms include swelling, pain, dysphagia, trismus, masticatory or speech disorders, refractory orocutaneous fistula, bone exposure, and even pathological fracture. MORN has become a challenging clinical problem for oral and maxillofacial surgeons to deal with, but thus far, this problem has not been solved due to the lack of widely accepted treatment algorithms or guidelines. Because of the nonexistence of standardized treatment criteria, most clinical treatment against MORN nowadays is largely based on controversial empirical understandings, while recommendations on post-therapeutic evaluations are scarce. Therefore, to further unify and standardize the diagnosis and treatment of MORN, to decrease the huge waste of medical resources, and ultimately, to improve the wellbeing of the patients, the Chinese Society of Oral and Maxillofacial Surgery (CSOMS) convened an expert panel specialized in MORN from 16 domestic medical colleges and affiliated hospitals to discuss the spectrum of diagnosis and and formulate treatment. In addition, consensus recommendations were also revised with a comprehensive literature review of the previous treatment experiences and research pearls. This 'expert consensus statement on diagnosis and clinical management of MORN' is for clinical reference.

Prophylactic Use of Pentoxifylline and Tocopherol in Patients Undergoing Dental Extractions Following Radiotherapy for Head and Neck Cancer

BACKGROUND

In head and neck cancer patients undergoing radiotherapy, osteoradionecrosis (ORN) of the jaw is one of the major but uncommon complications. Satisfactorily results have been observed while treating ORN patients with upcoming treatment modalities such as combination therapy of pentoxifylline and Vitamin E (PVe). It is believed that in patients undergoing dental extractions, these treatment modalities can be used prophylactically for lowering the risk of development of ORN. Hence, keeping all these things in mind, we planned the present study to assess the prophylactic role of pentoxifylline and tocopherol in patients who require dental extractions after radiotherapy for cancer of head and neck.

MATERIALS AND METHODS

A total of 110 patients were included in this retrospective study, which had radiotherapy for cancer of the head and neck. After radiotherapy, a total of 450 dental extractions were done in these 110 patients.

RESULTS

External beam therapy was given in 92.72% of the patients. 7.27% and 40% of the patients received intensity modulated radiotherapy combination of chemotherapy and intensity modulated radiotherapy, respectively. ORN developed only in 2 patients. Patients had taken PVe for a mean of 12 (24) weeks preoperatively and 14 (18) weeks postoperatively. The incidence was lower than that normally associated with dental extractions in irradiated patients.

CONCLUSION

In patients undergoing dental extractions, after receiving radiotherapy of head and neck region, combination therapy of pentoxifylline and tocopherol are sufficiently effective.

Pentoxifylline - a review of its use in osteoradionecrosis

Pentoxifylline has been used to treat complications related to fibrosis for over 20 years. Formerly used to treat those after radiotherapy such as osteoradionecrosis (ORN), it is now being tried for medication-related osteonecrosis of the jaw (MRONJ), which can occur after prolonged use of bisphosphonates. We review theories on the formation of fibrosis in patients with ORN, discuss the pharmacology of pentoxifylline and vitamin E, and report published outcomes. To our knowledge no prospective randomised controlled trial has investigated the benefits of these agents in cases of ORN, but reported outcomes in many published case series are encouraging.

Use of pentoxifylline and tocopherol in radiation-induced fibrosis and fibroatrophy

Radiation-induced fibrosis in the head and neck is a well-established pathophysiological process after radiotherapy. Recently pentoxifylline and tocopherol have been proposed as treatments to combat the late complications of radiation-induced fibrosis and a way of dealing with osteoradionecrosis. They both have a long history in the management of radiation-induced fibrosis at other anatomical sites. In this paper we review their use in sites other than the head and neck to illustrate the potential benefit that they offer to our patients.

Applying orthodontic tooth extrusion in a patient treated with bisphosphonate and irradiation: a case report

Bisphosphonates and irradiation are useful medical treatments, but can often cause oral complications such as medication-related oral necrosis of the jaw (MRONJ) and osteoradionecrosis (ORN) during oral surgery, including tooth extraction. Therefore, we should take all risks into consideration carefully before choosing dental treatment for patients with a medical history of such therapies. A 55-year-old woman who underwent cord blood transplantation to treat extranodal natural killer T (NK/T) cell lymphoma (nasal type IVB) had a medical history of bisphosphonate and irradiation treatments. We treated her residual tooth root by applying orthodontic extrusion to avoid extraction and successfully restored the tooth. Application of an orthodontic tooth extrusion technique for conservative treatment of a residual tooth is a useful means of avoiding MRONJ or ORN in patients who have a medical history of bisphosphonate and irradiation treatments.